GERD and the Breastfed Baby

GERD is an acronym for gastroesophogeal
reflux disease. Reflux occurs when stomach contents are spontaneously
returned into the esophagus. The main barrier to reflux is the lower
esophageal sphincter (LES). This is a band of voluntary muscle fibers
within the esophagus where it travels through the diaphragm from the
chest cavity into the abdominal cavity. Normally, there is enough pressure
within this area of the esophagus to prevent gastric contents from being
regurgitated from the stomach.

Causes

There are various reasons
why the LES stops being able to prevent reflux. An overfilling of the
stomach or increased gastric acid can overcome the LES. Many young babies
have periods when the LES relaxes, which allows reflux to occur. Forcibly
inhaling or exhaling can result in pressure changes that encourage reflux.
This type of breathing is often seen with cystic fibrosis, respiratory
infections, hiccups, and tracheomalacia (an abnormality of the trachea
which causes it to be unstable and prone to collapse). It is also a
symptom of bronchopulmonary dysplasia, which is a chronic pulmonary
disease that can develop in babies who have been placed on ventilators.

Nasogastric tubes that are
often used for feeding very premature or sick babies can decrease LES
pressure and also act as a pathway for reflux. In fact, premature babies
are generally more at risk for reflux, as are babies who are fed formula
rather than human milk. Food allergies are also thought to play a role
in some cases of GERD. In babies with hiatal hernias, the entire LES
and a portion of the stomach protrude upward through the diaphragm and
into the chest cavity, thus predisposing them to GERD.

Symptoms

The symptoms of GERD vary
from vomiting to breathing difficulties. A questionnaire that was developed
to help clinicians diagnose this condition (Orenstein et al 1996) revealed
the following behaviors to be highly indicative of GERD: spitting up
more than three times a day, spitting up more than a tablespoon, pain
associated with vomiting, crying after feedings, crying for more than
three hours a day, back arching and apnea (a temporary suspension of
breathing), or cyanosis (a bluish-gray discoloration of the skin caused
by lack of oxygen).

Babies may get into a pattern
of frequent, short feeds as they go on and off the breast in an attempt
to relieve the pain, or they may begin to reject feeding entirely. The
painful burning abdominal sensation that adults in the USA know as heartburn,
or pyrosis, causes a baby to fuss and cry usually within the hour after
feeding. This can also cause frequent night waking. When stomach contents
irritate the trachea or are actually aspirated (inhaled) into the lungs,
then choking, apnea, cyanosis or pneumonia can occur (Orenstein and
Orenstein 1988.) An infant who is merely spitting up frequently, but
is otherwise content and gaining weight, most likely presents only a
laundry problem. A baby who is in pain, not gaining, or not breathing
properly is showing signs of an illness that must be properly diagnosed
and treated.

Although there are some specific
tests for GERD, including swallow tests, pH probes, and endoscopy (visual
inspection of the esophagus by an optical instrument introduced within
a tube), these are invasive and stressful for babies and often give
inconclusive results. Therefore, many diagnoses are made by observing
symptoms. Doctors also need to rule out conditions such as pyloric stenosis
and metabolic dysfunctions, which can also cause vomiting and failure
to thrive. (Editor’s Note: Please refer to the Leader’s Handbook
for the scope and limits of the Leader’s role; as Leaders, we do
not attempt to diagnose, but as necessary we may encourage a mother
to seek advice from the appropriate health care professional. This article
is intended to enlighten the reader, not prepare the reader to diagnose.)

Treatments

In many cases, the baby’s
relaxed LES tightens up as he matures and reflux subsides as a function
of time. Overfeeding due to an overabundant milk supply or too forceful
milk-ejection reflex can result in vomiting and discomfort while feeding.
Proper breastfeeding management in these situations will often lead
to a rapid decrease in symptoms as mother’s milk supply lessens
to match her baby’s needs (Jozwiak 1995).

Breastfeeding itself is a
treatment for GERD—doctors often recommend frequent, small feeds
to promote gastric motility and emptying. Positioning is a standard
treatment for GERD no matter what the cause (Orenstein and Whitington
1983). Babies need to be maintained in a more upright posture, both
during and after feeds. It is recommended that the baby be held at a
45-60 degree angle while breastfeeding and that horizontal feeding be
avoided entirely. Between feeds, baby can be held upright through the
use of slings, soft baby carriers, or rigid carriers. However, baby
should not be allowed to slouch, so care must be taken and bolsters
may be needed to maintain baby in the proper position. Lying prone at
an angle, such as on someone’s chest also seems to work well.

Sucking on an “empty”
breast or even a pacifier helps by generating saliva (which neutralizes
acid) and promoting peristalsis (the involuntary, wave-like motion in
the GI tract that moves food along) that helps the stomach to empty
more quickly. Formula stays in the stomach longer and can contribute
to GERD (Heacock 1992). Since several studies have shown a strong link
between GERD and cow’s milk allergy (Iacono et al 1996), diet management
can be effective in this disease. Other common offenders are soy, eggs,
and wheat. A two-week elimination of all dairy products from mother’s
diet often produces noticeable improvement in a baby suffering from
cow’s milk allergy. Too much caffeine consumed by the baby’s
mother (which relaxes the LES) can cause a problem for some babies,
as can exposure to cigarette smoke (Alaswad et al 1996).

Medications may be used in
conjunction with other treatments. These include drugs that may counteract
stomach acids, decrease the production of acids, promote gastric motility
(movement of food out of the stomach and into the intestines), or increase
LES tone.

Thickened feedings are suggested
by many doctors. However, thickened feedings do not always work (Bailey
et al 1987), can interfere with breastfeeding, and may increase the
risk of food allergies. Some studies have shown that thickened feeds
can have an adverse effect on growth in some babies and increase the
risk of respiratory involvement (Orenstein et al 1992). Because thickened
feeds remain in the stomach longer, they may actually cause more reflux.
For these reasons, mothers should consider their options very carefully
before deciding to use thickened feeds. If a mother does want to try
this, she can use her expressed milk thickened with cereal and offer
it with a spoon before regular feedings at the breast. Surgery on the
LES is a rarely used treatment except in the most extreme and unresponsive
cases.

Studies have shown that formula-fed
babies are more likely to exhibit symptoms of GERD than are breastfed
infants. Weaning from the breast should not be regarded as a good solution
for GERD. Non-thriving babies should be evaluated for underlying illness.
In most cases, GERD can be handled through proper breastfeeding management,
positioning, mother’s diet, and education. When these steps do
not bring about relief, more extensive testing and other treatment options
may need to be explored.

Breastfeeding the
Baby with Reflux (pamphlet), La Leche League International
Available from LLLI, No. 524-24, $2.50
Breastfeeding Answer Book, Third Edition, La Leche League International
Available from LLLI, No. 1260-12, $68.00
Gaining and Growing-Assessing Nutritional Care of Preterm Infants: http://staff.washington.edu/growing/Feed/GER.htm

Sharon Knorr is a LLL Leader and Assistant Area Professional Liaison in upstate New York, USA. She is also a lactation consultant in private practice and in a local hospital. Sharon has two children (Joshua, 24; and Rachel, 21) and lives with her husband, Butch, in Newark, New York, USA. She has suffered from GERD for many years and hopes that this article will help babies to avoid some of her own unpleasant experiences with this condition.